Saving Costs and Lives: Reducing Opioid Prescribing to Injured Workers

When we as physicians enter the profession of medicine, we are instructed in the Hippocratic Oath and its tenet of First Do No Harm.  We take this as a mandate to go into the world and to alleviate suffering in all its forms.  For many years, opioid analgesics have played an integral part in the alleviation of suffering for patients with acute injuries, post-operative patients, and patients with terminal cancer.  However, as the prescribing of opioids has been expanded to chronic pain syndromes, a use for which there is no evidence of proven benefit, there has been a significant rise in the overall harm these medications have caused to patients and to society.

According to the Center for Disease Control and Prevention, opioid misuse and abuse is a national epidemic.  In 2014 more people died from accidental overdose of prescription opioids than died in motor vehicle accidents.   Another unintended consequence of opioid misuse and inappropriate prescribing is an increase in heroin addiction and heroin related death.

Fortunately, we are seeing a shift in doctors’ attitudes toward prescribing opioids for acute and chronic pain.  The American College of Physicians recently issued new guidelines for acute and chronic back pain that recommend the use of non-pharmacologic interventions, and many states are enacting new legislation to limit the prescriptions of opioids for acute pain.

The use of opioids for treatment of injured workers is characterized as especially problematic. The most important tenets of treatment of an injured worker are to restore full function and facilitate a safe and efficient return to work.  In a population of injured workers there is evidence that opioid use can delay recovery and return to work.  There is also the possibility of secondary gain by gaining a prescription for opioids or delaying return to work for patients who many not want to return to work or for whom return to work may be judged to be hazardous.  Per the ACOEM Guidelines published in November 2014, acute opioid treatment is not recommended for patients with safety-sensitive work including operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation and tasks involving high levels of cognitive function and judgment (Kurt T Hegmann, 2014).  As with all patients, injured workers should be carefully assessed for injury as well as psycho-social factors that may impair recovery, and they should treatment plans devised that seek to limit or eliminate use of opioid medication so that the patient can return to normal work as soon as possible.

Opioid misuse prevention is EVERYONE’S responsibility, and the onus falls on us as prescribers to do what we can to prevent harm from coming to our patients.   To enable this, we must create partnerships with our patients to bring awareness to the inappropriate use and expectation for opioid analgesics.    Clear patient education as well as empathic communication create an open and trusting patient-provider relationship that will allow us to meet the patient’s expectations of relief from suffering in a way that will ultimately facilitate a return to full function, rather than a long-term dependence on medication.

Start with education on the background of pain and analgesia

Treatment of pain is integral to the practice of medicine.  With increased knowledge of the pathophysiology of pain and pharmacology of analgesics, as well as with correct identification of pain type, severity, and causation, we can start to develop evidence-based and multimodality treatment plans to best alleviate the suffering of our patients.

It is important to differentiate between nociceptive and neuropathic pain when it comes to determining the best treatment plan for an individual patient.  Nociceptive pain is directly related to tissue injury and inflammation, whereas, neuropathic pain is a symptom of diseased and deficient neurons in the absence of discrete tissue damage.  Both types of pain can result in sensitization, or the upregulation and increased hyper-excitability of pain receptors.  Overtime sensitization can lead to hyperalgesia and/or allodynia (heightened pain response to minimal noxious stimulus or pain to otherwise neutral stimulus).  One key differentiation is that nociceptive pain is time limited by healing of damaged tissue and responds to NSAID and/or opioid analgesia depending on the severity of tissue damage that has occurred, whereas neuropathic pain is a neuro-biological disease that has little or no response to usual analgesics and may be better treated by atypical analgesics such as anti-epileptics, antidepressants, and/or infiltration of local anesthetic.  Current research, recently published in the Proceedings of the National Academy of Sciences of the United States of America, showed evidence in rats that even a short (five-day course) of morphine treatment could significantly prolong the experience of chronic neuropathic pain in a rat model. (Grace, 2016)

The main drawbacks of opioid analgesia as a class are related to reward, tolerance, physical dependence, and, of course, addiction. As most clinicians are aware, opioids are effective as analgesics because they block central nociceptive µ opioid receptors.  However, they also have significant effect on the dopamine reward pathways of the brain resulting in mood enhancement and even euphoria in some patients.   Many studies have illustrated that the opioid receptors modulate several behavioral effects including analgesia, reward, depression and anxiety.  The feedback loop of pain followed by reward results in upregulation of the patient’s desire to acquire more opioid analgesics.   The pain receptor will also become sensitized at an increased rate to obtain more and more opioids, and tolerance will build.  In my practice, I had a very simple way of explaining this feedback loop to patients:  Imagine your pain is a radio.  If the radio were too loud you could just throw a blanket over it to lower the volume, but you still want to hear the music, so you turn the radio up.  When it gets too loud you add a blanket and then also you want to hear it so you turn it up.  Now if you remove the blanket the music will be deafening.  When a patient takes opioids for analgesia, they do not remove the source of the pain, but they muffle the signal.  The body needs the source of the pain treated and/or desires additional activation of the dopamine reward pathway so it turns up the pain signal.   Now whenever the opioid starts to wear off the pain becomes unbearable so the patient believes they need more opioid.  What you have is the state of tolerance, or more drug required for the same response.  This was a very effective tool for patient education about opioids in my clinical experience.   Another drawback of chronic opioid use is physical dependence, or a withdrawal syndrome that manifests when the drug is removed.  Although nonfatal, opioid withdrawal symptoms produce significant discomfort, and patients may desire continuation of treatment to prevent withdrawal.  For this reason, planning a slow and steady exit strategy with patients on chronic opioid therapy is very important.  Finally, one of the most serious risks of opioid prescription misuse is opioid use disorder, a term synonymous with addiction.  This disorder is characterized by unsuccessful efforts to cut down on use, overuse, inappropriate use, and significant impairment in social functioning at work, school or home.  Having a history of opioid use disorder is also correlated with increased risk for opioid overdose and accidental death.

Provide the patient with alternative treatment recommendations

For all patients presenting with acute and chronic pain, non-opioid analgesia should be the first line – along with patient education and non-pharmacologic interventions.

When treating patients with acute pain consider non-pharmacologic therapy (ice, exercise, stretching, structured physical therapy programs) primary, even before non-opioid analgesia.  Aceatminophen and NSAIDS can be prescribed for patients with moderate (5-8/10) acute nociceptive pain.   Patient education on the importance of following a dosing schedule with tapering as pain begins to decreased is as important with non-opioid medication as it is with opioids.   Patients should be carefully counseled on usual or ordinary pain (<5/10) and appropriate lifestyle interventions to alleviate and prevent future exacerbations.

The Kura MD we have enacted a policy for opioid prescribing following the same standards as for limiting patient exposure to radiation, which is As Low As Reasonably Achievable.  This is based on the California Guidelines for Prescribing Controlled Substances for Pain recommendation that opioid analgesics only be prescribed after determining that other non-opioid medications or therapies likely will not provide adequate pain relief.  They also recommend prescribing the lowest dose and amount of medications for the shortest duration of time achievable (<1 week).  Significant patient education on the expectation for limited as needed use and prompt discontinuation of opioid medications should be undertaken prior to prescribing any opioid for pain.  The American College of Emergency Physicians (ACEP) recommends the following policy:

1. For patients with acute pain the physician should ascertain whether non-opioid analgesics and non-pharmacologic therapies will be adequate for initial pain management.
2. Given a lack of demonstrated evidence of superior efficacy of either opioid or non-opioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics.
3. If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (<1 week) and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.
4. Use the state prescription monitoring program prior to prescribing opioids to help identify those patients who are at higher risk for prescription opioid diversion and doctor shopping.

There are occasions when a Kura provider becomes the primary treating physician for a patient who is already receiving opioids for chronic occupational injury related pain, through a transfer of care from an astute nurse case manager.  In this scenario, prompt evaluation, consideration of risk factors, and education will be initiated.  The patient, who is likely physically dependent on opioids, will be counseled on an “exit strategy” and begin a safe tapering regimen to the lowest reasonably achievable opioid dose or complete elimination if possible.   ACOEM guideline recommend no more than 50mg/day morphine equivalent (for hydrocodone it is 1:1 (50mg) oxycodone ~2:1 (25mg)) for maintenance therapy of subacute and chronic pain, only in very select populations of individuals with documented objective results.  Careful monitoring of these patients with routine drug screening and monitoring of the state controlled substances database is also a company standard for those patients who are receiving opioids.

At Kura MD, we believe in doing what is right and necessary when it comes to alleviating the suffering of injured workers.   We also believe that injured workers should be treated as whole people within the society in which they live.   There is limited evidence for the use of opioids in treatment of acute musculoskeletal injury, and even less evidence for their use in chronic pain.  By partnering with injured workers, employers, and payers, Kura MD aims to reverse the tide of inappropriate use of opioids in a population of injured workers, and in society in general.

Bibliography

• Al-Hasani R, B. M. (2013). Molecular Mechanisms of Opioid Receptor Dependent Signaling and Behavior. Anesthesiology, 1363-1381.
• Deborah Dowell, M., Tamara M Haegerich, P., & Roger Chou, M. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain.
• Edmund G. Brown Jr., D. S. (2014). Guidelines for Prescribing Controlled Substances for Pain.
• Grace, P. e. (2016). Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation . Proceedings of the National Academy of Sciences, 113(24), E3441-E3450.
• Kaplovitch E, G. T. (2015). Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study. PLoS One.
• Kurt T Hegmann, M. M. (2014). ACOEM Practice Guidelines: Opioids and Safety-Sensitive Work.